Medicare Screening & Preventive Services

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Medicare Screening & Preventive

ServicesKentucky Health Department

TrainingApril 30, 2010

National Government Services, Inc.

Today’s Presenters• Lindy Lady, CPC• Donna R. Morton, CPC

Disclaimer• National Government Services, Inc. has produced this material

as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov.

Objective• Assist our health departments with correct

billing and coding for screening and preventive services covered by Medicare.

Acronyms• ABN – Advance Beneficiary Notice of Non-

coverage• BMI – Body Mass Index• CMS – Centers for Medicare and Medicaid

Services • CPC – Certified Professional Coder• DES – Diethylstilbestrol• DSMT– Diabetes Self Management Training• HBV - Hepatitis B virus

Acronyms• HIV - Human immunodeficiency virus• HDL - High-density lipoproteins• MLN - Medicare Learning Network• MMR – Medicare Monthly Review• MNT – Medical Nutrition Therapy• MPFS – Medicare Physician Fee Schedule• PPV - Pneumococcal polysaccharide vaccine• SIA – Supplemental Instruction Article

Services Not Included in the

Screening & Preventive Services Benefit

Services Not Part of Screening & Preventive Benefits

• 99385-99387, 99395-99397 Preventive Medicine Services (Not covered)

• S0613 Clinical Breast Exam (Not billed separately – part of G0101)

• 87491 Chlamydia (No LCD or NCD)• 87591 Gonorrhea (No LCD or NCD)• 86592 Syphilis test (L28535, A48037)

Services Not Part of Screening & Preventive Benefits

• 86701 – HIV-1 (NCD 210.7)• 88142 – Cytopathology, cervical or vaginal

(NCD 210.2)

Resource for Local and National Coverage Determinations

• www.NGSMedicare.com– Sign in as Part B Provider– Quick Links– Select Medical Policy Center

• In addition to LCD – review Supplemental Instruction Article (SIA)

Screening & Preventive Services

Frequency Count• Begin with the month after the last covered

service• Frequency of 24 months, 23 months must have

passed• Frequency of 12 months, 11 months must have

passed• Example – low risk patient, service paid

February 2010– Begin count March 2010– 11 months have elapsed as of February 2011

Screening Pelvic Exam

Screening Pelvic Exam • Medicare guidelines

– No physician order needed– State law may require order

• Performed by doctor of medicine or osteopathy, or authorized practitioner

• For all female beneficiaries• Includes a clinical breast exam

Screening Pelvic Examination

• Frequency– High-risk female

• Once every 12 months

– Asymptomatic female• Once every 24 months

• Childbearing age and presence of cervical or vaginal cancer within past three years

• Cervical/vaginal cancer risk factors– Early onset of sexual activity (under 16 years of age)– Multiple sexual partners (five or more in a lifetime)– History of a sexually-transmitted disease (including HIV

infection)– Fewer than three negative or any pap smears within the

previous seven years– DESexposed daughters of women who took DES during

pregnancy

• Coding– Exam

• G0101 Cervical or vaginal screening; pelvic and clinical breast examination

– Diagnosis• Low risk patient

– V72.31, V76.2, V76.47, V76.49

• High risk patient– V15.89

Screening Pelvic Exam • Must include at least 7 of the elements

CMS requires• Document in medical record all elements

performed• Review elements on page 116 of the CMS

Guide to Preventive Services– (ICN 006439)

Screening Pelvic Exam Reimbursement

• Based on the MPFS• Medicare Part B deductible does not apply• Coinsurance does apply

Screening Pap Tests

Screening Pap Tests• Medicare guidelines

– Physician order needed• Ordered and collected by doctor of

medicine or osteopathy, or authorized practitioner

• For all female beneficiaries

Screening Pap Tests• Frequency

– High-risk female• Once every 12 months

– Asymptomatic female• Once every 24 months

Screening Pap Tests• Childbearing age and presence of cervical or vaginal

cancer within past three years• Cervical/vaginal cancer risk factors

– Early onset of sexual activity (under 16 years of age)– Multiple sexual partners (five or more in a lifetime)– History of a sexually-transmitted disease (including HIV

infection)– Fewer than three negative or any pap smears within the

previous seven years– DESexposed daughters of women who took DES during

pregnancy

Screening Pap Tests• Coding

– Screening pap test• G0123, G0143, G0144, G0145, G0147, G0148,

P3000– Physician’s interpretation of screening pap

tests• G0124, G0141, P3001

– Physician obtains, prepares, and conveys smear to laboratory

• Q0091

– Diagnosis• Low-risk patient

– V72.31, V76.2, V76.47, V76.49

• High-risk patient– V15.89

Screening Pap Tests• Reimbursement

– Q0091, G0124, G0141, P3001 paid under physician fee schedule

• Deductible does not apply• Coinsurance applicable

• Other pap test codes paid under clinical fee schedule (100%)

• ABN for frequency limits

Smoking and Tobacco Use Cessation

Counseling

Smoking & Tobacco Use Cessation Counseling

• Furnished by physician or qualified non-physician practitioner

• Patient must meet one of these criteria:– Uses tobacco and has a disease or adverse

health effect linked to tobacco use– Takes a therapeutic agent whose metabolism

or dosing is affected by tobacco use

• Cessation counseling session defined– Face-to-face patient contact at one of

two levels• Intermediate (greater than 3 minutes up to

10 minutes) or• Intensive (greater than 10 minutes)

• Cessation counseling attempt defined– Physician or NPP

• Determines beneficiary meets eligibility requirements

• Initiates treatment with cessation counseling attempt

– Cessation counseling attempt includes• Up to four cessation counseling sessions (one

attempt equals up to 4 sessions)

• Frequency– Two cessation counseling attempts

every 12 months (up to 8 cessation counseling sessions)

• Coding– Counseling

• 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

• 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

• Coding– Diagnosis

• Appropriate and reflect patient eligibility for counseling

• Payment from Medicare carrier– MPFS– 80% of approved– Deductible and co-insurance applyhttp://www.cms.hhs.gov/MLNMattersArticles/

downloads/MM5878.pdf

Diabetes Related Services

Diabetes• Diabetes

– Fasting blood glucose 126 mg/dL or above– Two-hour post glucose challenge 200 mg/dL or

above– Random glucose test over 200 mg/dL

Diabetes• Pre-diabetes

– Fasting glucose level of 100-125 mg/dL– Two-hour post-glucose challenge of 140-199

Diabetes Screening Tests• Eligibility determined by risk factors

– Patient must have at least one• Hypertension• Dyslipidemia• Obesity (BMI 30 kilograms/m2 or above)• Previous elevated impaired fasting glucose or

glucose tolerance

Diabetes Screening Tests• Eligibility determined by risk factors

– Patient must have at least two• Overweight (BMI of greater than 25 but less than

30 kilograms/m2)• Family history of diabetes• Age 65 or older• History of gestational diabetes or baby weighing

more than nine pounds.

Diabetes Screening Tests• Physician or qualified NPP referral

required

• Frequency– Tested but not diagnosed pre-diabetic or

never tested• One test within a 12-month period

Diabetes Screening Tests• Frequency

– Diagnosed pre-diabetic• Two tests within 12-month period (not less than six

months apart)

• Deductible and coinsurance do not apply– 100% of clinical lab fee schedule

Diabetes Screening Tests• Coding

– Tests• 82947, 82950, 82951• Modifier TS–pre-diabetes

– Diagnosis• V77.1

• http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5895.pdf

Diabetes Self-Management Training (DSMT)

• Medicare guidelines• Physician or qualified NPP order required • Plan of care• Provided by individual associated with

accredited DSMT program

DSMT• Eligibility• At risk for complications from diabetes• Recently diagnosed • Previously diagnosed

DSMT• Frequency

– Initial training: 10 hours in 12 months– Follow-up training: 2 hours in subsequent

years • ABN

– Services denied over the limited number of hours

DSMT• Coding

– Training• G0108 Diabetes outpatient self-management training

services, individual, per 30 minutes• G0109 Diabetes outpatient self-management training

services, group session (2 or more), per 30 minutes– Diagnosis

• No specific required

• http://www.cms.hhs.gov/MLNMattersArticles/Downloads/mm5433.pdf

DSMT• Reimbursement

– MPFS– Deductible and coinsurance apply

Medical Nutrition Therapy (MNT)

• Physician referral• Provided by registered dietitian or nutrition

professional enrolled with Medicare• Eligibility

– Diabetic– Renal disease

• Coding– Service

• 97802 – Used once a year• 97803 – All individual reassessments and

interventions after initial (97802)• 97804 – All group visits• G0270, G0271 – Additional hours of MNT beyond

number of hours typically covered

• Coding– Diagnosis

• No specific required

• Frequency– Initial calendar year: 3 hours– Subsequent years: 2 follow-up hours

• Reimbursement– MPFS– Deductible and coinsurance apply

• ABN– Services denied over the limited number of hours

http://www.cms.hhs.gov/MLNMattersArticles/Downloads/mm5433.pdf

Covered Diabetic Supplies• Blood glucose monitors and supplies• Therapeutic shoes• Insulin pumps• DME MAC

– www.NGSMedicare.com– www.Medicare.gov

• Resources• Publications

Cardiovascular Screening Blood Tests

Cardiovascular Screening Blood Tests Coverage

• Total cholesterol test• Cholesterol test for High Density

Lipoproteins (HDL)• Triglycerides test

Cardiovascular Screening Blood Tests Coverage

• Physicians order required• Asymptomatic beneficiaries • Every 60 months

– Applies regardless of ordering pattern

Cardiovascular Screening Blood Tests Coding

• 80061 Lipid panel (must include 82465, 83718, 84478)

• 82465 Cholesterol, serum or whole blood, total – 80061 & 82465 – L27352, A47388

• 83718 Lipoprotein, direct measurement; HDL cholesterol

• 84478 Triglycerides

Cardiovascular Screening Blood Tests Coding

• V81.0 Special screening for ischemic heart disease

• V81.1 Special screening for hypertension

• V81.2 Special screening for other and unspecified cardiovascular conditions

Cardiovascular Screening Blood Tests Reimbursement

• Clinical laboratory fee schedule• Part B coinsurance or deductible does not

• http:/www.cms.hhs.gov/manuals/downloads/clm104c18.pdf

Immunizations

Pneumococcal Vaccine (PPV)

• No physician order or supervision required• State laws may require order and

supervision• Paid at 100%

– Deductible/coinsurance do not apply• Mandatory assignment on vaccine

PPV• Frequency

– Covered once in a lifetime– Revaccination for high-risk

• No PPV in last five years

PPV• Coding

– Vaccine • 90732 Pneumococcal polysaccharide

vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use

– Administration • G0009 Administration of pneumococcal

vaccine

PPV• Coding

– Diagnosis• V03.82 Need for prophylactic vaccination and

inoculation against bacterial diseases; other specified vaccinations against single bacterial diseases; streptococcus pneumonia (pneumococcus)

• V06.6 Need for prophylactic and inoculation against combinations of diseases, streptococcus pneumonia pneumococcus and influenza

Hepatitis B Vaccine (HBV)• Covered for beneficiaries at high or

intermediate risk for hepatitis B virus • Physician order and supervision required• Mandatory assignment on vaccine

Hepatitis B Vaccine• Coding

– Vaccine• 90740, 90743, 90744, 90746, 90747 (as

appropriate) – Administration

• G0010– Diagnosis

• V05.3

Hepatitis B Vaccine• Payment at 80% of approved• Medicare Part B deductible and

coinsurance apply

ABN and the Hepatitis B Vaccine

• ABN required– Patient not at intermediate or high-risk of

contracting HBV

www.cms.hhs.gov/MLNProducts/downloads/qr_immun_bill.pdf - 2010-03-08

Coverage Influenza • One vaccination per influenza season for

all beneficiaries• More than one per season if reasonable

and medically necessary• H1N1 vaccine covered as additional

preventive immunization service• No physician order or supervision needed

Influenza CPT/HCPCS Codes

90655 Split virus, preservative-free, for children 6-35 months of age, intramuscular use

90656 Split virus, preservative-free, for individuals 3 years and above, for intramuscular use

90657 Split virus, 6-35 month’s dosage for intramuscular or jet injection use

90658 Split virus, 3 years and above dosage, for intramuscular or jet injection use

90660 Influenza virus vaccine, live, for intranasal useG9142 H1N1 vaccine (effective 9/1/09) – not required

Administration and Diagnosis Codes

• Administration HCPCS codes:– G0008 for influenza virus vaccine seasonal

administration– G9141 for H1N1 virus vaccine administration

(effective 9/1/09)

Administration and Diagnosis Codes

• Diagnosis codes:– V04.81 for seasonal and H1N1– V06.6 on claims for influenza vaccine and

pneumococcal polysaccharide vaccine (PPV) when purpose of visit was to receive both

Medicare Payment – H1N1• Medicare pays for administration but not

vaccine itself– Vaccine will be furnished at no cost to all

providers– Administration reimbursed at same rate as

seasonal vaccine administration

ABN and the Influenza Virus Vaccine

• ABN required– Patient requests additional influenza

vaccination in same flu season– Medical necessity not justified

Resources• The Guide to Medicare Preventive Services for

Physicians, Providers, Suppliers and Other Health Care Professionals: http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf

• Quick Reference Chart: http://www.cms.hhs.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

• The Medicare Learning Network (MLN) Preventive Services Educational Products Web page: http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp

Resources• CMS Manuals

– http://www.cms.gov/Manuals/IOM/list.asp– Benefit Policy Manual (100-02)

• Chapter 15– Claims Processing (100-04)

• Chapter 18• Chapter 32

Best Resources for Updates and Policy Changes

• www.NGSMedicare.com– Sign in as Part B Provider

• Subscribe to Part B Listerve– Select New and Pubications– Select Listserve

• Medicare Monthly Review (MMR)– Quick Links– Select Medicare Monthly Review

Training Opportunities

• www.NGSMedicare.com– Sign in as Part B Provider– Calendar of Events, Part B

• Medicare Part B Basics 101– May 17 – Gilbertsville– May 19 – Frankfort– July 6 – Somerset– July 9 - Ashland

Medicare University Self-Reporting Instructions

• Event Number = 10120OBDRM1• Topic = KY Health Department Training

Screening and Preventive Services • Medicare University Credits (MUCs) = 2• # of Sessions = 1• Catalog Number = AA-C-????

Medicare University Credit Self-Reporting Instructions

To earn MUCs, you must self-report your attendance after this training event has ended:•Go to www.MedicareUniversity.com or•Go to www.NGSMedicare.com, select your business type and region, then select Go

– On the upper-right side of the page, select the Medicare University logo

– You will be redirected to an informational page about Medicare University

– Look toward the middle of the page (just above the Click & Learn; Come & Learn; and About MU sections) for Enter the Medicare University CBT Online System and link; Select this link and you will be redirected to the Medicare University log on screen

Medicare University Credit Self-Reporting Instructions– Log on to the National Government Services Medicare University

site via the log on screen at www.MedicareUniversity.com – Note: You will be prompted to enter your Medicare University log on ID

and password. If you don’t already have one, you may obtain one at this point

– Select Course Catalog from the left side menu– Select the Details button for the course entitled “KY Health

Department Training Screening & Preventive Services”– To locate and self-report today’s training event either look for the name

of the event or look for the Catalog ID number provided for this event– A new window will open providing the event description and information;

select the Enroll button (the screen will then refresh)

Medicare University Credit Self-Reporting Instructions– Next, select Curriculum List from the left side menu; locate the

self-reporting course you just enrolled in and select the Go button next to it

– A new page will open; select the Launch button on the new page and the course will load in a new window

– Enter the training event number (10120OBDRM1) and select the Submit button

Thank You!

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